Social forces may limit health reforms

The health care reform law gives federal health officials a new mandate to address the fact that racial and ethnic minorities tend to be sicker than the rest of the population.

But there are limits to what they can actually do about the problem. The root causes, public health experts say, are social forces such as poverty, poor schools and crumbling infrastructure that are outside the control of the Department of Health and Human Services.

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While there are some things HHS can do to improve minorities’ access to quality health care, broadly addressing health disparities requires the department “to lead in areas where [it has] no authority,” said James Marks, senior vice president of the Robert Wood Johnson Foundation.

The size of America’s health disparities is captured by some shocking statistics.

According to the Centers for Disease Control and Prevention, African-American babies die almost 2½ times as often as white babies in the United States; poor children are 43 percent more likely to have asthma than their better-off peers; and people without a high school diploma are almost twice as likely to develop diabetes as those who have more than a high school education.

The state of the health care system has contributed to these gaps, many experts on health care disparities say, and the reform law includes features that are intended to address them.

Expanding Medicaid and subsidized private insurance will provide coverage for millions of poor and minority Americans, they say — populations that are especially likely to be uninsured today. Improving the way doctors and hospitals deliver care may help, too, since research shows these groups are far less likely to get high-quality care when they do see a doctor.

On Monday, HHS Assistant Secretary for Health Howard Koh announced new final standards for measuring race, ethnicity, primary language and other characteristics in order to better track disparities and target interventions in the health care system. He also unveiled a set of health priorities known as “leading health indicators,” which include education levels as a measure of the country’s well-being.

But while such measures are important, said Steven Woolf, a physician who directs the Virginia Commonwealth University Center on Human Needs, “the lion’s share of the task is outside of health care.”

HHS has built on its mandate from the Affordable Care Act to expand collaboration with other departments to address health care disparities, including crafting an “action plan” and a strategy for public engagement. It also invested broadly in prevention, creating a $15 billion Prevention and Public Health Fund that public health researchers believe can especially benefit vulnerable populations while improving the nation’s health across the board.

But Jonathan Fielding, the public health director for Los Angeles County, whom President Barack Obama appointed to a panel advising HHS on prevention policy, said there may be a more effective way to improve health.

“If there was one thing you could do to improve health,” he said, it would be to “address the [high school] dropout rate.”

Improving education is a “wholesale strategy,” Fielding said, that addresses several health risk factors. It leads to better jobs that are more likely to offer health insurance, better housing that is less likely to be near sources of pollution and is closer to grocery stores with healthy food and greater health literacy so people know how to care for themselves.

“It’s not a panacea, [but] you press a single button and a number of indicators move in the right direction,” he said.